Herbal Medicine for Neonatal Jaundice

1. Herbal Medicine for Neonatal Jaundice J.Dehghani MD. Shiraz University of Medical Sciences

2. Stercobilin excreted in feces Urobilin excreted in urine Hemoglobin Globin Urobilinogen formed by bacteria Heme O2 Heme oxygenase CO Biliverdin IX NADPH Bilirubin diglucuronide (water-soluble) Biliverdin reductase NADP+ 2 UDP-glucuronic acid Bilirubin (water-insoluble) Bilirubin (water-insoluble) Ligandin SLC21A6 BLOOD CELLS KIDNEY reabsorbed into blood INTESTINE via bile duct to intestines (MRP2) UDP-glucuronosyltransferase LIVER Figure 2. Catabolism of hemoglobin

3. Neonatal Jaundice • Neonatal jaundice is a yellowing of the skin and other tissues of a newborn infant. • A bilirubin level of more than 5 mg/dL manifests clinical jaundice in neonates whereas in the adults 2 mg/dL would look icteric. • In neonates the dermal icterus is first noted in the face and as the bilirubin level rises proceeds caudal to the trunk and then to the extremities • Neonatal jaundice occurs in about 2/3 of all healthy newborns.

4. Physiologic Jaundice • R/O pathologic causes such as infection, hemolysis, metabolic disorders • 12mg/dl for term, 15mg/dl for preterm and 15-17 for exclusive breast feed • Direct Bilirubin < 1 (1.5-2)

5. Cause of Physiologic Jaundice • Increase Production • Immature liver (Ligandin, Glucronyl Transfrase)

6. Pathologic Jaundice • in first 24 hrs • More than 0.5 mg/dl/hr • More than 13 mg/dl in term neonates • Direct Bili > 1.5 • Hepatosplenomegaly or anemia

7. Cause of Pathologic Jaundice • Increased production • Fetomaternal blood group incompatibility: Rh, ABO • Hereditary spherocytosis. • Non-spherocytic hemolytic anemia: G-6-PD deficiency, a-thalassemia, Vitamin K induced hemolysis, pyruvate kinase deficiency. • Sepsis. • Increased enterohepatic circulation: Pyloric stenosis, or large bowel obstruction. • Decreased clearance • Inborn errors of metabolism: Criggler-Najjar syndrome type I and II • Drugs and Hormones: Hypothyroidism, breast milk jaundice.

8. Current Treatment of Jaundice • increasing the frequency of feedings is indicated. optimal breastfeeding (eight to 12 times per day) increases removal of bilirubin through the gastrointestinal tract and ensures continued breastfeeding. • Phototherapy • Intensive Phototherapy • Exchange Transfusion • Pharmacological Treatment with Phenobarbital and Heme Oxygenase Inhibitors (Mesoporphyrin)

9. Mechanism of Phototherapy

11. Yin Zhi Huang for Jaundice

12. Hyperbilirubinemia • Bilirubin is highly hydrophobic, and chronic hyperbilirubinemia results in its deposition in the central nervous system, causing neurotoxicity and encephalopathy. • Some evidence suggests that chronic jaundice may also suppress the immune system as well as other normal physiological functions

13. For the last several decades, phototherapy has been used to treat neonatal jaundice. Recently, however, both older and more recent pharmacological approaches to jaundice have been considered • Phenobarbital, which induces UGT1A1 activity • there are also numerous remedies for jaundice in various traditional medicines. Yin Zhi Huang and a number of other herbal decoctions containing Yin Chin have been used for centuries in Asia to prevent and treat neonatal jaundice • Yin Zhi Huang contains extracts from four different plants: Artemisia capillaris, Gardenia jasminoides Ellis, Rheum officinale Baill, and Scutellaria baicalensis Georgi.

14. Artemisia capillaris • Yin Chen Hao • درمنه • کاسنی • Detoxification

15. Gardenia jasminoides Ellis • Zhi zi • Family: Rubiaceae • قهوه • طعم دهنده. افزایش تمرکز

16. Rheum officinale • Rhubarb • Polygonaceae • کرفس • مسهل

17. Scutellaria baicalensis • Lamiaceae • Anxiolytic

18. Several clinical reports in the Chinese medical literature indicate that Yin Zhi Huang treatment can enhance bilirubin clearance in newborns • In studies in rats, both Yin Zhi Huang and phenobarbital induced bilirubin glucuronyl transferase and GST activity, and Yin Zhi Huang had a somewhat more potent stimulatory effect on bilirubin clearance than phenobarbital

19. Constitutive androstane receptor (CAR) NR1I3 has been shown to mediate the response of liver to phenobarbital and other “phenobarbital-like” compounds • CAR is a key regulator of the bilirubin clearance pathway and that CAR activation increases the rate of bilirubin clearance

20. Xenobiotic Receptors • Aryl hydrocarbon receptor (AHR) • Pregnane X receptor (PXR) steroids, antibiotics, antimycotics, bile acids, hyperforin, a constituent of the herbal antidepressant St. John's Wort, and many other herbal compounds. • Peroxisome proliferator-activated receptor (PPARs) • Constitutive androstane receptor (CAR) It is known to act in concert with PXR to detoxify xenobiotics

21. Methods

22. boiling 40 g Artemisiae, 14.6 g Gardenniae, 7.2 g Rheum, and 12 g Scutellariae in water for 30 minutes and adjusting the final volume to 40 ml. • Mice were hosted in a pathogen-free animal facility under a standard 12-hour light/12-hour dark cycle. • A humanized CAR transgenic mouse

23. Different groups of mice appropriately matched in genetic background (n = 3–4) were injected i.p. with a solvent (corn oil) or 1,4-bis[2-(3,5-dichloropyridyloxy)]benzene (TCPOBOP) (3 mg/kg), 5-pregnen-3β-ol-20-one-16α-carbonitrile (PCN) (40 mg/kg), and 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) (100 μg/kg) for 3 days. [4-Chloro-6-(2,3-xylidino)-pyrimidynylthio]acetic acid (WY-14,643) (0.1%) was added to the food, and the mice were fed for 1 week.

24. TCPOBOP CAR • PXR  PCN • PPARα  WY-14,643, • AhR  TCDD

25. For Yin Zhi Huang or Yin Chin treatments, appropriately matched groups of mice were gavaged once daily for 3 days with a Yin Zhi Huang or Yin Chin decoction (10 ml/kg/day) • For 6,7-dimethylesculetin treatment, the compound was first dissolved in a small volume of DMSO and then mixed well with corn oil. Groups of WT and CAR null mice were injected i.p. twice daily for 3 days with vehicle control or 6,7-dimethylesculetin (100 mg/kg).

26. On the fourth day, the animals were intravenously infused with bilirubin solution (10 mg/kg) via the tail vein. • After 1 hour, blood was collected and total serum bilirubin was determined as described. Livers were removed and total bilirubin from liver was measured

27. Northern hybridization. • β-actin serving as a control for equivalent loading. • CYP2B10,UGT1A1,GST1,2, SC21A6

28. Results

29. CAR regulates the bilirubin clearance

30. Yin Zhi Huang stimulation of bilirubin clearance is dependent on CAR

31. Human CAR can mediate response to Yin Zhi Huang

32. Dimethylesculetin Vs hydroxyacetophenone.

34. Overall, we concluded that 6,7-dimethylesculetin is a specific CAR activator that is likely to contribute to the ability of Yin Zhi Huang to increase bilirubin clearance.

35. Discussion

36. CAR is a key regulator of bilirubin clearance. Under ordinary circumstances, CAR is sequestered in the hepatocyte cytoplasm and thus does not affect bilirubin levels. In response to elevated bilirubin levels, however, CAR activates expression of multiple components of the bilirubin clearance pathway, resulting in an increased rate of clearance. • the results described here indicate that acute activation of CAR has a particularly significant impact on the overall bilirubin clearance rate, although it remains possible that important functions for the other receptors would be observed under other circumstances.

37. disease is thought to be a consequence of imbalances in the body, and it is often considered necessary to incorporate multiple components into a therapeutic approach to restore balance to different processes. • 6,7-dimethylesculetin is an active component of Yin Zhi Huang and other Yin Chin–containing herbal medicines that contributes to their biological effects. Particularly because previous studies indicate that extracts of the other plants in Yin Zhi Huang can increase GST or UGT1A1 activity ,it is possible that other components also contribute.

38. It is intriguing that Artemisia species related to Yin Chin have been used in traditional medicines from many cultures for a variety of indications, including liver ailments, and a number of studies in animal models indicate hepatoprotective effects for various Artemisia extracts These effects have been attributed to antioxidant or other properties of the components of these extracts, but it is an interesting possibility that CAR activation is a contributing factor.